Copyright @ 2012 , Hillier, J.

Critical Review: Effects of mild to moderate sensorineural hearing loss on the language development of
school aged children

John Hillier
M.Cl.Sc (AUD) Candidate
University of Western Ontario: School of Communication Sciences and Disorders

Language development, in school aged children with permanent mild to moderate sensorineural hearing loss
(MMSHL), has been given little consideration with few studies devoted to the subject. Children with MMSHL often
face many obstacles in the domain of language development as the characteristics of their hearing loss often lead to
language input being degraded and distorted. This critical review examines the research on the effects of MMSHL
on normal language development. The selected research papers address the effects of minimal and moderate
permanent hearing loss on certain factors of language development in school aged children and if these language
delays persist as the child ages. The research concludes that children with MMSHL do perform poorly in certain
linguistic skills, such as phonology and syntax. Three of the four studies included in this paper linked poor
performance in these areas to more complex difficulties in language and communicative ability.

MMSHL has been associated with deficiencies in

Introduction frequency discrimination, expressive language and in
production of verb morphology. It has also been
Recently, it has been suggested by a number of concluded that children with MMSHL experience
researchers that mild to moderate bilateral sensorineural difficulties in phonological processing (Moeller,
hearing loss (MMSHL) does have a significant effect on McCleary, Putman, Tyler-Krings, Hoover &
the language development of a school aged child. Stelmachowicz, 2010). Due to a number of
Despite this discovery there have been few studies misconceptions concerning children with MMSHL
conducted to investigate and define the precise educators and other professionals may conclude that
difficulties that may arise. Due to the dearth of these children may not be suffering any major
published research there remains a lack of awareness by difficulties due to their hearing loss. However, it should
professionals who work with school aged children as to be realized that the disrupted auditory input due to
how these difficulties exactly affect normal language MMSHL that occurs during the time of normal language
development. development may cause deficiencies and delays in
certain linguistic skills (Norbury, Bishop & Briscoe,
Briscoe, Norbury and Bishop (2001) define mild 2001).
hearing loss as a pure tone average threshold of 20 dB
HL to 40 dB HL whereas their definition of moderate Objectives
hearing loss is thresholds ranging from 40 dB HL to 70
dB HL. Presently, this definition is universally accepted The primary objective of this paper is to critically
amongst researchers. In the past, the primary focus of review selected studies that present evidence concerning
research, for a number of reasons, was on the the effects of mild to moderate sensorineural hearing
management of children with severe to profound loss on the language development of school aged
hearing loss. With advancements in hearing assessment children. A secondary objective is to identify and
and screening and the ability to reliably detect milder discuss the clinical implications of this research.
losses, researchers have begun to turn their attention to
populations with less severe hearing loss. Until the Methods
1980s and the initial work of Fred Bess it was the
prevalent belief that school aged children, who suffer Search Strategy
from milder degrees of sensorineural hearing loss, do The following databases were included in the literature
not experience any considerable difficulties in language search:, PubMED and Medline. The search strategy was
development (Tharpe, 2008). However, current research as follows:
now indicates that these children may have significant (mild to moderate hearing loss) AND (sensorineural
difficulties in a number of aspects of language hearing loss) AND (language development)
development which could possibly have far reaching Limitations on the search included: studies in English
effects on the child’s communicative ability and and all children (0-18 years). Google Scholar was used
scholastic achievement throughout the individual’s life to supplement the search of academic databases to
(Delage & Tuller, 2007). Research has shown that identify any obscure or grey literature.
 Copyright @ 2012 , Hillier, J.

Selection Criteria younger. This led the researchers to conclude that

Articles selected for this review included studies that degraded auditory input during this period of language
researched the effects of mild to moderate sensorineural acquisition may cause delays in the development of
hearing loss on the language development of school certain language skills.
aged children.

Data Collection Briscoe et al. (2001)

The articles that corresponded to the above literature In this paper, the researchers use a case-control study to
search and met the selection criteria included three case assess and compare the phonological skills, language
control studies that investigated the effects of mild to ability and literacy scores of children with MMSHL and
moderate sensorineural hearing loss on language, children with SLI. The two clinical samples were
literacy and various linguistic skills such as phonology, recruited and compared with two control groups of
morphosyntax and morphology. The fourth article normally developing children. Included in the MMSHL
retrieved involved longitudinal research on the language group were children who had a mild (PTA 20-40 dB
development of children with late identified mild to HL) to moderate (41-70 dB HL) bilateral sensorineural
moderate hearing loss. Two of these articles (Moeller et hearing impairment, were attending mainstream school
al, 2010; Delage and Tuller, 2007) also investigated the and were not using sign language. Each child was
normalization of language skills in adolescents with administered a battery of tests including standardized
MMSHL. language assessments as well as tests of phonological
awareness, phonological discrimination, expressive
Results phonology and digit recall. Scheffe tests set at p < .05
Children with MMSHL and development of language showed very few significant differences between the
Norbury et al. (2001) MMSHL group and the SLI groups. It was shown that
In this study, Norbury et al. compare the production of the MMSHL group and the SLI group were equally
verb morphology of two groups: children with specific impaired on tests of phonological awareness,
language impairment (SLI) and children with MMSHL. phonological discrimination and nonword repetition.
The authors of this paper are interested in However, the MMSHL group did not show any of the
morphological development in children with moderate deficiencies in language and literacy which were
degrees of hearing loss. Their research is primarily prominent in the SLI group. Subsequently, the
concerned with how degraded auditory input affects researchers analyzed the data of the hearing impaired
learning of finite verb morphology. This study included group based on whether they were impaired or
four groups of children: a MMSHL group, a SLI group unimpaired on the phonological tasks. This was to
and two control groups. It should be noted that one further examine the extent certain factors, such as,
control group was matched on age and nonverbal ability severity of hearing loss, age of diagnosis of hearing
to the SLI and MMSHL groups and the other was loss, or general cognitive ability have on phonological
matched on language-age to the SLI group. deficits in children with MMSHL. T-tests were
. conducted and no significant differences between the
The researchers used analysis of variance (ANOVA) to impaired and unimpaired groups in age were found:
compare group means on all language assessments. To unimpaired mean =8.78, impaired mean = 8.53 years;
identify patterns amongst the subgroups the post-hoc t(17)=0.39, p=.0705. The two groups also did not differ
Scheffe test was conducted. Results revealed that on age at diagnosis of hearing loss: 49.2 months for
children in the MMSHL group had most difficulty on those without phonological impairments: 47.1 months
measures of expressive language. This group also for those with phonological impairments. However, the
scored significantly poorer on measures of phonological two groups did differ in degree of hearing loss. ANOVA
processing than the age matched control group [F(3, 62) showed a significant effect of subgroup, F(1, 17) = 7.56,
= 9.26, p <.001 ƞ2 =.309]. A series of t-tests was p = .014 but no interaction between subgroup and
conducted to identify differences in the MMSHL group. frequency, F (4,68) = 0.29, p=.280. The study showed
The groups were determined depending on whether the that there were some differences in language literacy
children were impaired or unimpaired on tense marking skills, with the phonologically impaired group
tasks. It was shown that the impaired group (6 children) performing worse. However, the researchers ultimately
and the unimpaired group (13 children) differed concluded that, despite there being a link between poor
significantly on language measures such as receptive phonological awareness and phonological
vocabulary and grammar, expressive verb vocabulary discrimination with vocabulary acquisition, there is no
and phonological discrimination. T-tests also showed relation between poor performance on phonological
that these two groups differed significantly in age tasks and other language abilities or literacy.
(t=3.99, p=.001) with the impaired group being
 Copyright @ 2012 , Hillier, J.

production of morphological errors. At baseline, all four

Delage and Tuller (2007) of the children with MMSHL fell below the lower limits
The purpose of this study was to evaluate the nature of of the 95% confidence interval for the control group.
the link between hearing loss and language impairment One of the questions the researchers explored was
in adolescents with mild-to-moderate hearing loss. whether the spoken language skills of the MMSHL
Nineteen monolingual French speakers ranging in age group normalized with age. Results indicated that with
from 11 to 15 years were recruited. All subjects suffered age and intervention three of the four children showed
from bilateral sensorineural hearing loss with thresholds improvement. However, the researchers further reported
between 27 dB to 69 dB. These adolescents were that delays persisted in speech production, production of
compared to two control groups and a group of children fricatives and morphology. They believe these results
with SLI. Language and literacy skills were assessed are attributable to the combination of degraded
with a battery of standardized tests including tests of audibility and reduced auditory experience due to the
phonology, as assessed by a word repetition task, hearing impairment during the early period of language
expressive grammar and reading. To define language acquisition.
impairment, scores on the standardized tests were
converted to z scores. The authors chose the threshold of Critical Appraisal of Selected Case Control Studies
< -1.65 SD which corresponds to the fifth percentile in Case control studies are designed to explore factors that
the normal distribution as the cutoff score for difficulty. contribute to a certain condition of a patient by
Scores on these tests showed that adolescents with comparing patients with the condition of interest (case)
MMSHL had difficulties with phonology (63. 2% to patients who do not present with the condition
participants with scores < - 1.65 SD) and morphosyntax (controls). The Oxford Centre for Evidenced Based
(31.6% with scores < -1.65 SD). Similar difficulties Medicine place case control studies as level 2b
were seen in the SLI group but not the control groups. evidence. It is expected that studies ranked this highly
There were few difficulties seen in other language in the Oxford Hierarchy should yield valid and
skills, such as oral comprehension, written language and important evidence. Greenhalgh (1997) suggests that the
vocabulary for the MMSHL group. Spearman two most important factors of the research design of a
correlation tests were conducted to determine links case control study to consider are the diagnosis of
between language performance and other variables. A “caseness” and how the decision of when the individual
link was found with degree of hearing loss and became a case is made.
performance in expressive grammar (r = -.51, p <..05)
and in word repetition (r =-.61, p<.01). Subjects with Strengths of Selected Case Control Studies
higher degrees of hearing loss performed worse on these All of the case control studies selected for this paper
measures. Results from this study showed that more employ sensible research design and explore pertinent
than half of the children in the MMSHL group and salient questions, which have rarely been
performed poorer than control groups in areas of investigated. The researchers of the case control studies
phonology and grammar and language scores were have used statistical analysis to show that the results
linked to degree of hearing loss. were statistically significant, thus increasing the validity
of the evidence. For example, Delage and Tuller (2007)
Longitudinal study of language development and use the nonparametric Wilcoxon test appropriately to
language normalization analyze within groups data. The studies also define the
Moeller at al. (2010) characteristics of the groups being investigated. In their
This study was the first longitudinal study that paper, Briscoe et al. (2001) clearly outline the
examined the effects that late-identified mild-moderate thresholds of the children in the MMSHL group. The
hearing loss can have on a child’s language researchers also attempt to limit confounding factors by
development. Longitudinal measures were taken excluding children with certain characteristics such as
throughout the study and changes were noted and neurological impairment or other comorbidities. To
analyzed. Baseline results indicated that, as compared to further strengthen the evidence presented researchers
the normally developing control group, the hearing attempted to match the case and control groups on
impaired children performed poorly on measures of factors such as age and other characteristics such as
phonology. In particular, all four of the MMSHL nonverbal ability. All language assessments were
children had difficulty producing fricatives and the standardized and significant bias in outcome assessment
immaturity of their consonant inventories, suggested is unlikely for the selected studies.
marked delays in consonant production. The deficits in
phonology were also accompanied by impaired Limitations of Selected Case Control Studies
production of morphology for three of the children in The research designs of the studies did also include
the MMSHL group as evidenced by the persistent some limitations. One limitation of the study conducted
 Copyright @ 2012 , Hillier, J.

by Norbury et al. (2001) involves the fact that the phonology and syntax are most prevalent as these
researchers only recruited students from mainstream language skills are the most susceptible to atypical
schools to take part in their research. This could result development during this period. It must be noted that
in sampling error and confound the results of the study. there is a great deal of intersubject variability and not all
To avoid this problem, the researchers could have children with MMSHL suffer from delays in language
recruited subjects from both mainstream schools and development or show long term effects (Delage &
children who were educated in specialist units. Tuller, 2007). A number of researchers have concluded
Additionally, the sample sizes for all three case control that children with MMSHL are at increased risk for
studies were relatively small (19-20 children for each psychoeducational deficits and poor scholastic
study). This limitation could negatively impact the achievement (Tharpe, 2008). This statement is in
power used to accurately make conclusions about the contrast with the findings of certain studies identified in
effects of the condition. this paper. Briscoe et al. (2001) found that the
deficiencies in phonology and expressive language
Critical Appraisal of Longitudinal Study found in some of the children suffering from MMSHL
The selected longitudinal study was a comparative study could not be linked with large scale problems in
with concurrent controls and is therefore ranked as level language and literacy. However, Delage and Tuller
2b evidence according to the Oxford Centre for (2007) suggest that long term impairments in language
Evidence based medicine hierarchy. Strengths of this development due to degraded auditory input, may be
study include the design. For example, children with severe enough for some adolescents with MMSHL, to
hearing loss were age-matched and compared to experience delays in school. Moeller et al. (2010) have
children with normal hearing. Baseline measures were similar findings to those of Delage and Tuller. In their
taken near the point of identification and standardized longitudinal study, these researchers found that, despite
measures of language assessment were used. The the normalization of certain linguistic skills, their group
limitations of this study include a small sample size of children with late identified MMSHL still had
(n=4) and the fact that the authors of this study did not persistent delays in speech intelligibility. This
use any statistical methods to determine if there were impairment in speech intelligibility was compounded by
any significant differences between the impaired difficulties in phonological skills, especially the
hearing group and the normal hearing group. production of fricatives, and morphology. Research has
shown that children with such difficulties are prone to
Having considered the strengths and weaknesses of each speech errors and have difficulty making themselves
study, the research presented in the case control studies understood due to a lack of vocabulary (Tharpe, 2008).
can be categorized as compelling. However, due to a It is therefore possible that these deficits could
small sample size and lack of statistical analysis the negatively affect the communicative ability and
evidence presented in the longitudinal study could be psychoeducational development of these children.
considered suggestive.

Discussion Clinical Implications

There are a number of clinical implications which arise
All four of the papers examined in this study found from the research surveyed in this paper. Firstly,
fairly strong evidence of significant differences between awareness is an issue when it comes to the effects of
children with MMSHL and normally developing MMSHL on natural language development. Studies
children in the domain of language development. The conducted on this subject are rare and there are certain
majority of these difficulties involved impairments in myths surrounding the development of children with
phonology and expressive language. Two of the studies MMSHL because of this lack of knowledge. Many
(Delage & Tuller, 2007: Moeller et al., 2010) found professionals believe that preferential seating in front of
evidence that adolescents with MMSHL may still the classroom is sufficient for children with MMSHL
display relatively severe language impairments. This (Goldberg & Richburg, 2004). Teachers and other
would indicate that delays in language development professionals should be advised that degraded auditory
persist in certain children. It has been shown that the input has been shown to affect the language
language skills of these children do improve with age, development of children with MMSHL. Therefore other
as compared to younger children with MMSHL, considerations, such as FM systems, should be made in
however they do continue to show poorer performance order to ensure that the child is receiving proper
than their normally developing peers on certain auditory input.
language production tasks. The early school years
encompass the critical period for language development Secondly, at this moment, many universal newborn
(6 to 7 years). It is this reason that impairments in hearing screening programs are deigned to identify
 Copyright @ 2012 , Hillier, J.

moderate or worse sensorineural hearing loss and often Delage, H. & Tuller, L. (2007). Language development
consider children with milder degrees of hearing loss as and mild-to-moderate hearing loss: does
unwanted false positive results (Wake, 2006). These language normalize with age? Journal of
guidelines may need to be reviewed as Moeller et al. Speech, Language and Hearing Research, 50,
(2010) show that children with late identified MMSHL 1300-1313.
demonstrate language delays. Goldberg, L. & Richburg, C. (2004). Minimal hearing
impairment: major myths with more than
Conclusion minimal implications. Communication
The findings of the research discussed above indicate Disorders Quarterly, 25, 152.
that children with MMSHL have difficulty in their Greenhalgh, T. (1997). Assessing the methodological
development of certain linguistic skills. Furthermore, a quality of published papers. British Medical
number of the studies linked these deficits with more Journal, 315, 305-308.
complex difficulties in language and communicative Moeller, M., McCleary, E., Putman, C., Tyler-Krings, A
ability. However, additional research should be Hoover, B., & Stelmachowicz, P. (2010).
conducted to identify factors which would predict which Longitudinal development of phonology and
children with MMSHL would be at highest risk for morphology in children with late-identified
these difficulties as there is much intersubject variability mild-moderate sensorineural hearing loss. Ear
within this population. Increasing awareness in teachers and Hearing. 31, 625-635.
and other professionals who work with children with Norbury, C., Bishop, D., & Briscoe, J. (2007).
MMSHL as to difficulties that these children may Production of English finite verb morphology:
experience would also be recommended for the future. a comparison of SLI and Mild-Moderate
Hearing Impairment. Journal of Speech,
Language and Hearing Research, 44, 165-178.
Tharpe, A. Unilateral and mild bilateral hearing loss in
children: past and current perspectives. (2008).
References Trends in Amplification, 12. 7-15.
Briscoe, J, Bishop, D. & Norbury, C. (2001). Wake, M., Tobin, S., Cone-Wesson, B., Dahl, H.,
Phonologial processing, language and literacy: Gillam, L., McCormick, L., Poulakis, Z.,
a comparison of children with mild-to- Rickards, F., Saunders, K., Ukoumunne, O &
moderate sensorineural hearing loss and those Williams, J. (2006). Slight/Mild hearing loss in
with specific language impairment. Journal of children. Pediatrics, 118, 1842-1851.
Child Psychology, 42, 329-340.